Authorization to Disclose Health Information

I, the undersigned individual below, declare under penalty of perjury under the laws of the state in which I am located that I am the Patient named above, and hereby request my medical records as set forth in this Patient Request to Access Medical Records form.

By signing below, you certify your understanding that your medical records to be disclosed under this Authorization are protected under Federal Confidentiality regulations (42 CFR Part 2}. Published August 10. 1987, and the Heath Insurance Portability and Accountability Act of 1996 (P.L. 104-191 ), 42 U.S.C. Section 1320d, et. Seq, and cannot be disclosed without your written consent unless otherwise provided for in the regulations.

Unless sooner revoked, this Authorization expires in 12 months or upon termination of your treatment at Northpoint Recovery, whichever is later; provided that the Authorization shall expire in 12 months to the extent it authorizes disclosure of medical records to a financial institution or to my employer for purposes other than payment.

By signing below, you certify your understanding that you might be denied services if you refuse to authorize disclosure of your medical records for purposes of treatment, payment, or health care operations, if permitted by state law. You will not be denied services if you refuse to authorize the disclosure of your medical records for other purposes.

Unless you have requested in writing that disclosure be made in a certain format, we reserve the right to disclose medical records as permitted by this Authorization in any manner we deem to be appropriate and consistent with applicable law, including but not limited to verbally, in paper format, or electronically.

You understand that medical records used or disclosed pursuant to this Authorization may be disclosed by the recipient and may no longer be protected by federal or state law. Each disclosure of medical records subject to 42 CFR Part 2 made by Northpoint with your written consent will be accompanied by the following statement: “42 CFR Part 2 prohibits unauthorized disclosure of these records.”

You understand that you have a right to revoke this Authorization, in writing, at any time by sending written notification to medicalrecords@northpointrecovery.com. You further understand that a revocation of the Authorization is not effective to the extent that action has been taken in reliance on this Authorization. You may request a copy of this Authorization for your records by emailing medicalrecords@northpointrecovery.com.

I certify under penalty of perjury pursuant to the law of the state in which I am located that I am the patient named above. I hereby hold harmless and release and forever discharge Northpoint and its affiliated entities from all claims, demands, and causes of action which I, my heirs, guardians, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of reliance on this Authorization.

I consent to receive a copy of this Authorization, and communicate with Northpoint and its affiliated entities, via unencrypted email at the email address provided above. I acknowledge that unencrypted email messages could be intercepted by unauthorized third parties or read by other people who have access to email account. With knowledge of these risks, I consent to the receipt of unencrypted email messages.